Provider Demographics
NPI:1700072808
Name:LEWIS, MARY B (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2295
Mailing Address - Country:US
Mailing Address - Phone:574-722-9633
Mailing Address - Fax:574-722-5987
Practice Address - Street 1:3400 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2295
Practice Address - Country:US
Practice Address - Phone:574-722-9633
Practice Address - Fax:574-722-5987
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000994A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000550574OtherANTHEM BLUE CROSS
IN200932700Medicaid
INP00626250OtherRAILROAD MEDICARE
IN000000550574OtherANTHEM BLUE CROSS